Gastroenterology II: Ulcerative Colitis & Crohn's Disease

Question 1

Describe the anatomy of the lower GI tract.

Answer 1

The lower GI tract runs from the small intestine to the large intestine to the anus.

look at slide

Question 2

What is coeliac disease?

Answer 2

Gluten sensitivity/intolerance associated with HLA B8 tissue type with a prevalence of ~1 in 1800 but it is under-diagnosed in most people

Question 3

How does coeliac disease present?

Answer 3

Presents with change of bowel habit (COBH):
-Pale, bulky, offensive, greasy stool

-Abdominal colic:
Abdominal pain that comes and goes in waves

-Weakness; weight loss

-Short stature/failure to thrive

Question 4

What are the classical GI symptoms of coeliac disease?

Answer 4

-Diarrhoea (45-85%)
-Flatulence (28%)
-Borborygmus (35-72%) a rumbling or gurgling noise made by the movement of fluid and gas in the intestines.
-Weight loss (45%)
-Weakness; fatigue (80%)
-Abdominal pain (30-65%)
-Secondary lactose intolerance
-Steatorrhea

Question 5

What are the classical extra-intestinal symptoms of coeliac disease

Answer 5

Anaemias (10-15%): especially Fe, B12

Neurological symptoms (8-14%)

Skin disorders (10-20%) e.g dermatitis herpetiformis-maculopapular pruritic.

Endocrine disturbances including infertility, impotence, amenorrhea, delayed menarche

Question 6

What investigations should you undertake to diagnose coeliac disease?

Answer 6

Serology test check for the presence or level of specific antibodies in the blood look at slide 8.

Question 7

How is coeliac disease treated?

Answer 7

Gluten restriction curative in 95%

Refractory in 5%- so use corticosteroids (poor outcome)

Involve dietician, support groups, on-line recipes

Read labels including medications, cosmetics, etc.

Question 8

What is important to be aware of if someone has coeliac disease?

Answer 8

Although rare, remember there is increased risk of lymphoma and adenocarcinoma of the pancreas, oesophagus, small bowel, biliary tract, including T & B cell non-Hodgkin’s lymphoma.

Question 9

What are some long-term effects of coeliac disease?

Answer 9

People with it are more likely to be affected with problems relating to malabsorption, including:

-Osteoporosis
-Tooth enamel defects
-Central & PNS disease
-Pancreatic disease
-Internal haemorrhaging
-Organ disorders
-Gynaecological disorders

Question 10

What is the dental relevance of coeliac disease?

Answer 10

Problems related to malabsorption:

-B12, folate, ferritin: can orally manifest as glossitis, angular cheilits, anaemia, burning mouth, smooth tongue

-Vitamin K: bleeding tendency

-Vitamin D:osteomalacia and rickets in children

Enamel defects may occur in the permanent dentition if the onset is in childhood

Question 11

Contrast the environmental aetiology between Crohn’s & UC.

Answer 11

Appendicectomy = removal of the appendix

look at slides

Question 12

How does Crohn’s manifest?

Answer 12

Patchy distribution of ‘skip lesions’ is quite common.

Question 13

Contrast the epidemiology of Crohn’s disease & ulcerative colitis (UC).

Answer 13

Crohn’s:

-Slightly less common (27-106/100,000)
-Females: 1.2:1
-Younger: 26

UC:
-Slightly more common (80-150/100,000)
-Males: 1.2:1
-Older: 34

Question 14

Is the aetiology of Crohn’s & UC well known?

Answer 14

No, but there are concerns about genetic tissue types, polygenic inheritance patterns, & familial patterns, as well as host immunology.

slides 16

Question 15

Contrast the pathology of Crohn’s with UC.

Answer 15

Backwash ileitis- inflammatory reaction in the distal ileum

look at slides 18

Question 16

What is Crohn’s disease?

Answer 16

Chronic Inflammatory bowel disease, specifically chronic and recurring inflammation of the GI tract.

Aetiology unknown - inflammatory response to intestinal microbes + environmental factors + genetic factors.

Question 17

How do patients commonly present with Crohn’s disease?

Answer 17

-Intermittent abdominal pain, diarrhoea, abdominal distension (90%)

-Decreased appetite- anaemia and weight loss (50%)

-Fresh blood or melaena (40%)

-Fistulae and perianal sepsis (20%)

-Episodes of flares with asymptomatic intervals

Question 18

What are some symptoms of Crohn’s disease?

Answer 18

Fat wrapping, cobble-stoning and thickened wall of the vessels

Question 19

What are the 3 phenotypes of Crohn’s disease?

Answer 19

Stricturing: gradual thickening of intestinal wall- leads to stenosis/ obstruction

Penetrating: intestinal fistulas (abnormal passage from one organ to another) between GI tract and other organs (can occasionally be external fistulas-skin)

Non-penetrating: anal fissures, abscesses

Question 20

What characterises Crohn’s in terms of macroscopic changes?

Answer 20

-Bowel is thickened
-Lumen is narrowed
-Deep ulcers
-Mucosal fissures
-Cobblestone
-Fistulae
-Abscess
-Apthoid ulceration

Question 21

Contrast the microscopic changes in Crohn’s disease against UC.

Answer 21

Crohn’s:
-Transmural
-Lymphoid hyperplasia
*Granulomas

UC:
-Mucosal (chronic inflammatory cells: lamina propria)
-Goblet cell depletion
-Crypt abscess

Question 22

How do you diagnose Crohn’s disease?

Answer 22

Diagnosis:

-Barium enema: rose thorn, skip lesion, string sign

-Sigmoidoscopy and biopsy, colonoscopy

-Differential diagnosis includes TB and sarcoidosis

Question 23

How do you treat Crohn’s disease?

Answer 23

Symptomatic relief; reduction of inflammation; increase Quality Of Life

Medical- glucocorticoids

immunomodulators

biologics

Surgical- intestinal resection

Question 24

What are the specific lesions you get in Crohn’s disease?

Answer 24

-Diffuse labial and buccal swelling
-Cobblestones
-Mucosal tags
-Linear ulcers
-Mucogingivits
-Staghorning - enhancement of submandibular ducts
-Granulomatous Cheilitis - swollen lips

Question 25

What are the non-specific lesions you get in Crohn's disease?

Answer 25

-Aphthous ulcers -Angular Cheilitis -Glossitis -Dental Caries -Gingivitis/Periodontitis

Question 26

What does orofacial granulomatosis (OFG) have similar signs & symptoms to?

Answer 26

Crohn's disease (concurrent Crohn's occurs in ~40% of children diagnosed with OFG).

Question 27

Who is OFG more prevalent in?

Answer 27

Children & young adults

Question 28

What benefits 70% of people with OFG?

Answer 28

Avoiding cinammon & benzoates

Question 29

What is UC (ulcerative colitis)?

Answer 29

Chronic inflammatory bowel disease where there is diffuse mucosal inflammation of the colon with backwash involvement of the terminal ileum: rectum always involved.

Question 30

What is the hypothesis behind the aetiology of UC?

Answer 30

Dysregulated interaction mucosal immunology & intestinal microflora, and genetic predisposition.

Question 31

How do patients with UC commonly present?

Answer 31

Painless, bloody diarrhoea with mucus Associated fevers and remission periods where the patient returns to near normal

Question 32

Visually compare UC and Crohn's disease:

Answer 32

UC = Ulceration, surviving mucosa (pseudo-polyps), loss of haustra.

Question 33

Visually compare a normal colon and a colon affected by ulcerative colitis:

Answer 33

Absence of goblet cells Crypt distortion and abscess Affects mucosal layer only

Question 34

What is the risk with UC?

Answer 34

Chronic inflammation leading to colorectal cancer

Question 35

How do you diagnose UC?

Answer 35

Colonoscopy and biopsy- findings include exudates, ulcerations, loss of vascular pattern, friability , continuous granularity (very fragile, bleeding) Superficial inflammation with loss of haustration

Question 36

How do you treat UC?

Answer 36

High protein, high fibre diet 5-ASA (5- amino salicyclic acid), sulphasalazine & mesalazine, thioprines, corticosteroids Surgery

Question 37

What do extra GI manifestations of UC look like?

Answer 37

It can include these issues: -Occular (uveitis, episcleririts, conjunctivitis) -Renal (Gall stones, fat liver, hepatitis, sclerosing cholangitis) -Dermatological (erythema nodosum, pyoderma gangrenosum) ORAL -Hepato-billiary -Vascular -Skeletal

Question 38

What is the dental relevance of UC?

Answer 38

Oral manifestations: Pyostomatitis vegetans (PV)- benign, multiple small white and yellow pustules, erythematous/oedematous background (‘snail track’ ulcers) ^Primary involved sites include labial attached gingivae, soft/hard palate, buccal mucosa, sulcus The intestinal symptoms usually precede PV

Question 39

What are some other common conditions to have alongside UC?

Answer 39

-Aphthous ulcers -Tongue coating -Gingivitis -Periodontitis -Halitosis -Acidic taste -Cutaneous manifestations

Question 40

What investigations would you carry out for IBD?

Answer 40

look at sldes

Question 41

How do you generally treat IBD (inflammatory bowel disease)?

Answer 41

+ imaging = lead pipe sign/string signing or thinning of parts of the bowel. Chest x-rays looking for perforations

Question 42

If concerned about UC or Crohn's, what should you ask your patient about?

Answer 42

-Rashes -Mouth ulcers -Joint/back pain -Eye problems -Family history -Smoking status

Question 43

Which meds work better for Crohn's & UC?

Answer 43

Crohn's: -Azathioprine -Methotrexate -Cyclosporin -Humera (adalimumab/anti TNF) -Steroids for flares UC: -Aminosalicylates (mesalazie) -Steroids (foam/PR; oral; IV) -Azathioprine

Question 44

Does surgery work in IBD?

Answer 44

Surgery can be curative for UC but 80% of Crohn's have resections and generally it helps very little.

Question 45

What are some indications for surgery in UC?

Answer 45

Acute: -Failure of medical treatment for 3 days -Toxic dilatation -Haemorrhage -Perforation (hole) Chronic: -Poor response to medical treatment -Excessive steroid use -Non compliance with medication -Risk of cancer I CHOP = acronym for main indication for surgery

Question 46

What are the prognoses for Crohn's & UC?

Answer 46

UC: -1/3 have single attack -1/3 have relapsing attacks -1/3 progressively worsen requiring colectomy within 20 years Crohn's: -Varied prognosis, new biological agents improving Cancer: -Both have increased risk of colon cancer, though UC>Crohn's Screening colonoscopy done every 2 years after 10 years disease and every year after 20 years disease

Question 47

What are some predisposing factors for carcinoma of the colon?

Answer 47

Neoplastic polyps, UC FH, familial polyposis coli, previous cancer.

Question 48

How does carcinoma of the colon present

Answer 48

Depends on the site: Left colon- bleeding per rectum, change in bowel habit, and tenesmus Right colon- anaemia, weight loss & abdo pain Both- obstruction, perforation, haemorrhage/fistulae Troisier's sign/Virchow's node (enlargement of left-sided supraclavicular lymph node)

Question 49

Difference between colostomy and ileostomy:

Answer 49

Colostomy : the surgical creation of an artificial excretory opening between the colon and the body surface Ileostomy: creation of an artificial opening into the ileum

Question 50

What are some examples of functional bowel disorders?

Answer 50

Diverticular disease Irritable bowel syndrome Herniation= tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles.

Question 51

What are the potential differential diagnoses of IBD?

Answer 51

IBS is the most common first diagnosis of many GI disorders and therefore can mask other inflammatory conditions.